The battles of the Finnish Civil War ended in the late spring of 1918, but the aftermath of the war was only beginning. Conditions were favourable for the spread of infectious diseases like smallpox—a disease historically described as “leaving villages deserted and driving even victorious armies into retreat.”
Smallpox, variola—history’s deadliest killer?
Pathogens are part of the ecosystem, just like humans. The spread of diseases and microbes was particularly facilitated by the domestication of animals about 12,000 years ago, as microbes gained new hosts when humans and animals began living in close proximity. The adaptation between a parasite and its new host progresses in stages, from epidemic to endemic: an epidemic occurs when a community first comes into contact with a new pathogen and has little to no defence against it. If the epidemic spreads to a large part of the world, it becomes a pandemic. Those who survive the epidemic and contract the disease often develop better resistance or immunity. Eventually, the disease becomes endemic, meaning it becomes a common infectious disease.
Smallpox is one of the world’s most infamous infectious diseases, and the only disease to have been eradicated globally thanks to vaccines. In 1980, the World Health Organization (WHO) described smallpox at its General Assembly as a disease that “was a most devastating disease sweeping in epidemic form through many countries since earliest time, leaving death, blindness and disfigurement in its wake”. About one-third of those infected with smallpox—hundreds of millions of people—died.
Smallpox spreads through droplet transmission and belongs to the variola virus group. Variola viruses are part of the orthopoxvirus genus, which also includes viruses causing diseases such as cowpox and monkeypox. The incubation period for smallpox is about 7–17 days, and the most common early symptoms include high fever, headache, and muscle pain. According to a 1915 newspaper description, the initial symptoms were followed by a reddening rash that became pustular, “disfiguring the victims’ faces” and emitting a “sweet odour.” About two weeks after the onset of the disease, the rash turned into scabs, which made it easy to identify those infected. After three weeks, the scabs fell off, causing intense itching.
It was impossible to have smallpox unnoticed, as survivors bore large and visible scars across their bodies. About 30% of survivors had visible scars, which could cause blindness by fusing the eyelids shut. Infertility and other lifelong injuries were also common consequences of the disease. The most frequent causes of death among smallpox patients were complications from the widespread rash, bacterial infections, and multiple organ failure.
A Disease that thrived in crowded living conditions
The prevailing theory today is that smallpox first transmitted from cows or monkeys to humans during prehistoric times. However, urbanization in particular enabled the spread of epidemics when enough people settled permanently in a sufficiently dense area. The rapid spread of contagious diseases required not only dense living conditions but also the movement of people and goods. Conditions like this, in turn, facilitated the spread of epidemics for example during and after the Finnish Civil War. Social customs of the time, such as bidding farewell to the deceased or repurposing the belongings of those who died from the disease, also contributed to the rapid spread of diseases.
By the early 20th century, there was awareness of the rapid transmission and dangers of smallpox, but this did not prevent, for example, the reuse of the good clothes of deceased victims.
Vaccinations for protection, despite opposition
An significant early discovery had been made in the study of smallpox regarding immunity. Those who had contracted and survived smallpox did not get sick again: the disease either killed its victims or provided long-term immunity. By the time the civil war broke out, cowpox inoculation had been used for over 100 years to dramatically reduce smallpox mortality. In the 1700s, smallpox was inoculated from an infected person to a healthy one, but English physician and scientist Edward Jenner developed a method in which cowpox was used instead of smallpox. The goal was to achieve a permanent immunity without a person contracting smallpox through droplet infection, which was much more dangerous than the implanted smallpox. After inoculation, a person could experience symptoms such as fever, fatigue, nausea, skin conditions, or scabs at the vaccination site. Inoculation, also known as vaccination or variolation, involved making scratches with a sharp knife or needle on the arm, into which the vaccine, developed from cowpox, would be inserted. Three days after vaccination, a lump would appear in the scratch, which would develop into a blister over 8–9 days. Slowly, the blister would dry up, and in the best case, the cowpox inoculation was fully successful. Cowpox inoculation began in Finland in 1802, and compulsory smallpox vaccination, ordered by the emperor, came into effect in 1883, making vaccination mandatory and requiring it to be repeated every 10–15 years.
Recent studies have shown that during the 1900s, there was some opposition to smallpox inoculation in Finland, which was often directed at the mandatory nature of the vaccination, not necessarily the vaccine itself. Among the opponents of compulsory vaccinations, the supporters of natural healing, who opposed modern medicine, were the largest group. Anti-vaccine arguments on the grounds of self-determination and ideology are still used today and were also used in public debate during the civil war.
Smallpox in the early 20th century Finland
In the 19th century, the theory of dirt’s connection to diseases became widespread when connections between the poor living conditions of workers and diseases began to be studied. Dirty living conditions were particularly believed to cause smallpox, and flies in homes were cited by contemporary sources as disease spreaders. In the early 20th century, the impact of expensive, poor and inadequate living conditions on the spread of smallpox was highlighted, particularly by opponents of vaccination. Cleanliness was emphasized in newspaper articles in 1917 as a way to combat smallpox. In the 1920s, Terveydenhoitolehti (The Healthcare Journal) dedicated a September issue to smallpox treatment guidelines. According to contemporary sources, people were aware of the importance of hygiene in avoiding disease, for example by washing their hands and using soap.
The worst smallpox epidemics in the early 20th century occurred during and immediately after the First World War, from 1916 to 1919. The spread of the disease due to the war and the high mobility of people was also reported in newspapers.
In 1916, it was reported that 310 cases of smallpox were detected in Finland, although there had been no cases in previous years, and the world war was blamed for the spread of smallpox in 1917 as well. The spread of the disease can be seen to have been caused not only by increasing mobility of people but also by the world war, which probably brought new worries to people, who were no longer able to keep up with their vaccinations regularly. In retrospect, it is easy to see that, even if vaccination was not necessarily on top of people’s minds, it would have been particularly important during the world war.
Smallpox in Finland during the civil war
In the spring of 1918, smallpox spread from Russia to Finland, becoming an epidemic among the Red Guard troops and on prison camps. Cases were recorded at all major prison camps. Smaller camps, where only local prisoners were held, were spared the epidemic.
In the post-civil war prison camps, diseases spread particularly easily due to overcrowding, poor hygiene, and a lack of resources: there were not enough nurses, doctors, or vaccines. During the First World War, approximately 500,000 doses of smallpox vaccine were produced annually in Finland, but this was no longer sufficient by 1918. Scarlet fever, smallpox, and often the subsequent skin infections caused by streptococcus, leading to high mortality rates in prison camps. The waves of the Spanish flu epidemic led to deaths in the prison camps also. The food shortages that came with the world war and the poor conditions of the prison camps were widely reported, and the conditions in the camps were made a subject of interpellation in Parliament as early as the summer of 1918.
In early June, the Hamina newspaper reported: "The feeding of prisoners has, of course, not been at a satisfactory level, depending on the general food shortage throughout our country."
In early June, the Hamina newspaper reported: “The feeding of prisoners has, of course, not been at a satisfactory level, depending on the general food shortage throughout our country.” In July 1918, the Vaasa newspaper Ilkka reported that it had visited the prison camp: The Vaasa prison camp housed 860 prisoners, of whom 81 were in the hospital, and only one had died of smallpox, but none had died from hunger. All prisoners, like the officials, had been vaccinated, and the prisoners were allowed to go to the sauna once a week. According to reports, the conditions in the Vaasa prison camp were relatively good due to the small size of the camp. Mortality or the spread of disease was not as common as in other larger camps, which became centres of the epidemic. In the 1910s, party politics were a part of the press, and the Vaasa-based Ilkka was a bourgeois newspaper, which likely helped to embellish the conditions of the Vaasa prison camp.
Smallpox in Tampere and Kanta-Häme
Doctors in the Tampere district knew that smallpox had been sporadically present “throughout the entire rebellion,” but accurate numbers of disease and death cases were not generally known during the civil war. In February 1918, the municipal doctor of Messukylä near Tampere reported three clear cases of smallpox, but the actual wave of infections did not begin until April among the Red Guard troops. The strategic importance of the Tampere–Toijala railway line became clear during the Battle of Tampere, and Red Guard troops were stationed in the area around Toijala station. By the end of April, several smallpox cases were reported among the Red Guard troops stationed in Toijala.
Like elsewhere in Finland, the main challenges in the fight against smallpox in Tampere was the shortage of vaccine, which the White Senate had promised to supply to the White Guard troops in March 1918 to maintain their combat readiness. Despite planning, for example, Colonel Harald Hjalmarsson’s White Guard regiment of 2,000 men were still unvaccinated during the Battle of Tampere in late March.
The patient lists of the Tampere prison camp begin in mid-April, and the exact vaccination dates for all prisoners are not available. According to parliamentary session records, by mid-May, 79 out of 6,894 prisoners at the Tampere prison camp had contracted smallpox. By the end of the month, around 95 prisoners had contracted smallpox, and at least six prisoners with suspicious symptoms were isolated from the 10,000 Red prisoners held in Tampere.
The population of Tampere had been widely vaccinated against smallpox 2–3 years earlier. After the battles, on May 8, 1918, the city’s chief physician ordered 2,000 vaccine doses to vaccinate prisoners, guards, and soldiers. “Those who had previously not been vaccinated” were encouraged to get vaccinated, although the city’s civilian doctors were unable to organize a large-scale response against smallpox.
The Kanta-Häme region became one of the core areas of the smallpox outbreak. The shortage of vaccine was a problem, but in addition, “quite a few of the prisoners tried to avoid vaccination by all possible means”. According to contemporary sources, much to the frustration of the doctors, new groups of unvaccinated prisoners were transported to the area daily, and despite the doctors’ warnings, were “pushed into the ranks of the already vaccinated.” By July 7, it was reported that 1,106 people had died of smallpox at the Hämeenlinna prison camp, although the number was considered “greatly exaggerated” by the camp’s chief medical officer. Due to the interpellation in Parliament, inspections were carried out at the prison camps, during which it was confirmed that there were 560 cases of smallpox at the Hämeenlinna prison camp by early July. No specific number of smallpox deaths was provided in the inspection.
Viipuri and Lahti in the grip of smallpox
Smallpox occurred sporadically during the war months of 1918 in the civilian population on the red side of Viipuri Province, as well as in the troops of the Red Guard. On March 19, 1918, the Red Guard’s Viipuri military district headquarters warned frontline ambulance units of the appearance of contagious diseases such as smallpox and ordered the separation of the sick and wounded from one another. All “suspiciously ill” individuals were to be isolated in the frontline conditions and a doctor’s diagnosis of the disease was to be sought. Once “the nature of the disease had been determined,” those suffering from contagious diseases were to be sent directly to an isolation hospital, separate from others. The headquarters considered the establishment of temporary isolation hospitals near the front line to be advisable.
Red Guards stationed in local houses in the Viipuri area contracted smallpox, likely because many local residents who had worked in Russia had not been vaccinated or had purposely avoided receiving booster vaccinations during the war. However, smallpox spread most severely in areas where there was anti-vaccine sentiment for one reason or another: particularly the so-called “Kirvulaiset” in Kirvu, who believed in natural healing and opposed modern medicine – and thus also vaccinations.
By the end of April 1918, dozens of people suffering from smallpox were isolated in the temporary hospitals of the Viipuri Red Guard: Red Guards, local civilians, and war refugees. Newspapers reported on June 6 and 9, 1918, that smallpox had “spread so rapidly” that the three existing isolation hospitals were no longer sufficient: the workers’ association house was designated as a smallpox hospital, and new cases were no longer allowed to be transported to Viipuri but had to be treated in their hometowns.
At the Viipuri prison camp, the forced vaccination of red prisoners was seen as important, and they were carried out. However, the vaccination of red prisoners partially failed during the first attempt in May 1918, when the nationwide shortage of smallpox vaccine led to a reduction in the number of vaccination points or “inoculation sites,” and some prisoners wiped the vaccination marks on their clothes. In follow-up examinations, no signs of reaction were found in some of the vaccinated, and immunity could not be confirmed. The revaccination was carried out as it is for young children’s annual vaccinations: prisoners were kept under the watch of guards, with their arms exposed until the vaccination mark had scabbed over. Despite the slow start, smallpox did not spread as an epidemic in the Viipuri prison camp or its sub-camps, although vaccination coverage was not immediately comprehensive due to resistance from the prisoners.
During the last battles in the Lahti area in late April 1918, the Red troops spread smallpox to all the municipalities in which they were stationed. The actual epidemic disaster began on May Day 1918 when 28,000 Western Finnish Reds, along with their families, surrendered near Lahti.
The doctors took note of the contagious diseases observed in the refugee groups and prisoners: two cases of smallpox were diagnosed on May 1. By early June, smallpox continued to spread in the Lahti area, particularly at the Hennala prison camp, where 55 smallpox cases and 25 cases of confluent smallpox were diagnosed, with “some of these cases ending in death.”
It is certain that 3,000 Reds contracted smallpox between April and June 1918, with 900 dying from various complications, but not all sudden deaths or prison hospital records were transferred to prisoner files. Therefore, the true number of smallpox deaths cannot be determined.
Post-war debates in the newspapers
In newspaper articles from 1919, the civil war had largely been left behind, but smallpox and vaccines were still relevant topics, with varying attitudes toward them in different parts of the country. According to the Tampere-based Aamulehti, in the organized conditions of the cities, smallpox did not spread as easily: people in cities were more aware of diseases and their transmission and were more cautious. The article claimed that people living in rural areas did not believe in the contagious nature of smallpox, hid infections, and believed in old superstitions. Consequently, caution was not observed. Modern research has shown that rural residents were generally more indifferent toward vaccines than urban dwellers, and ideological opposition to vaccines was especially strong in rural areas.
In 1921, the newspaper Karjalainen published an article titled "Population Losses Caused by the Red rebellion and the War of liberation." The article counted the deaths of those who died from various diseases in the prison camps as part of the "Red rebellion" toll, estimating that over 10,000 people perished.
In 1921, the newspaper Karjalainen published an article titled “Population Losses Caused by the Red rebellion and the War of liberation.” The article counted the deaths of those who died from various diseases in the prison camps as part of the “Red rebellion” toll, estimating that over 10,000 people perished. The prisoners who died were categorized under the diseases they were known to have contracted, including various “fevers” such as smallpox, typhus, and measles, as well as “other diseases,” which also included the Spanish flu, which did not have its own specific disease classification. The boundary of classification was quite blurry, as the Spanish flu was listed under both other diseases and fevers. The causes of death during the fever phase of smallpox and many other diseases often remained unclear, especially when the death occurred at the beginning of the disease. During the war and after it, conditions were favourable for illness, particularly for those without vaccine protection. Many became ill, and not all cases could be diagnosed immediately, with some of the most seriously ill dying before their disease could even be recorded.
The knowledge of the varying classifications of diseases and the deceased is significant. Today, the civil war and the deaths during and after it are popular subjects for research. If contemporary sources knew that causes of death were recorded randomly and variably, depending on the locality or the individual, it is quite challenging for modern researchers to determine the true causes of death and the numbers of those who contracted or died from specific diseases.
Even in 1925, newspapers continued to analyse the 1918 disease catastrophe: the challenges of vaccinating prisoners during the civil war were attributed to a shortage of vaccine, which led to the suspension of mandatory vaccinations at prison camps up to three times. Contemporary sources about vaccinations, combined with earlier research, indicate that although Red prisoners were sentenced to death and executed, the spread of contagious diseases like smallpox was not wanted in the prison camps, which is why vaccinations were considered essential, regardless of the personal opinions of the prisoners.
Conclusion
At the beginning of the 20th century, smallpox was still one of the most dangerous infectious diseases, and its horrors were well known. Although cowpox vaccines had reduced mortality, the increased movement of large masses of people still posed a risk of contracting smallpox, which had wreaked havoc for millennia. The Finnish Civil War, part of World War I, brought its own set of challenges, which affected people’s willingness to get vaccinated. There was also a shortage of vaccine material. Conditions in the civil war prison camps were cramped, poor, and unhygienic, with food shortages contributing to the spread of infectious diseases. These factors created a fertile ground for the spread of smallpox and other diseases. The last smallpox epidemic in Finland occurred in 1936, after which subcutaneous vaccines became more common. Smallpox cases occurred sporadically until the 1940s, when the disease had virtually disappeared from Finland. Smallpox vaccinations were given to Finns until the 1970s, and in the 1980s, the World Health Organization declared smallpox to be the first disease eradicated worldwide through vaccination.
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